10 FATHEK'S MOTHER'S FATHEB 



1. Date of birth. Birthplace and origin. 



2. Occupation. Residences. 



3. Age at 1^ The place for this entry 



marriage, j is at 4 in next page. 



, r -r 1 The place for this entry 



4. do. of wife > ■ . ■ ^ 



^ j IS at 3 in next page 



5. Mode of life so far as 

 affecting growth or health. 



9. Bodily strength and 

 energy, if much above 

 or below the average. 



10. Keenness or imperfection 

 of sight or other senses. 



1 1 . Mental powers and 

 energy, if much above 

 or below the average. 



1 2. Character and 

 temperament. 



13. Favorite pursuits 

 and interests. 

 Artistic aptitudes. 



14. Minor ailments to ( in youth, 

 which there was -' 

 special liability ( in middle age. 



( in youth. 

 15. Graver illnesses ■' 



( in middle age. 



16. Cause and date of death, and age at death. 



17. General remarks. 



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